A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?
Identify the given instrument.
A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?
A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?
A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?
A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?
Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?
A homosexual man complains of painful defecation and mass protruding from the anal canal. Biopsy reveals squamous cell carcinoma of anus. Correct management for this patient is
A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?
A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?
FMGE 2023 - Surgery FMGE Practice Questions and MCQs
Question 11: A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?
- A. Fistulogram
- B. USG
- C. CECT
- D. MRI (Correct Answer)
Explanation: ***MRI*** - **Gold standard investigation** for fistula-in-ano for preoperative assessment - Provides **superior soft tissue contrast** and multiplanar imaging capabilities - Accurately delineates the **fistula tract, internal and external openings** - Detects **secondary tracts, horseshoe extensions, and abscesses** - Helps in **Parks classification** (intersphincteric, trans-sphincteric, suprasphincteric, extrasphincteric) - Essential for **surgical planning** and predicting recurrence risk - MRI with fat suppression sequences (T2-weighted) provides best visualization *Fistulogram* - Outdated investigation with **limited accuracy** (40-50%) - Cannot adequately assess sphincter involvement or secondary tracts - Invasive and uncomfortable for the patient - Risk of extravasation and infection *USG (Endoanal/Transperineal Ultrasound)* - Useful adjunct but **not gold standard** - Operator-dependent with limited field of view - Difficulty visualizing high or complex fistulas - Less accurate for secondary extensions *CECT* - Not routinely used for fistula-in-ano assessment - **Inferior soft tissue resolution** compared to MRI - Radiation exposure - Limited differentiation of sphincter anatomy
Question 12: Identify the given instrument.
- A. Curved stapler
- B. Circular stapler
- C. Linear stapler (Correct Answer)
- D. Skin stapler
Explanation: ***Linear stapler*** - The instrument shown has a long shaft with two jaws that apply staples in a straight line, which is characteristic of a **linear stapler**. - It is primarily used in **abdominal** and **thoracic surgery** for transecting tissue or closing internal organs like the stomach, intestines, or lung parenchyma. *Skin stapler* - A **skin stapler** is a much smaller, handheld device used exclusively for closing skin incisions externally and has a distinctly different appearance. - It applies single, wide staples and is not used for internal tissue anastomosis or transection. *Circular stapler* - A **circular stapler** has a round head at the distal end designed to create a circular, end-to-end anastomosis, typically in **colorectal** or **esophageal** surgery. - The instrument in the image lacks this circular head and is designed for a linear staple line. *Curved stapler* - This term most commonly refers to a **circular stapler** or a **curved linear cutter**, which has a curved head to facilitate access in locations like the pelvis. - The instrument shown has straight jaws, not a curved head, and is designed for creating a straight line of staples.
Question 13: A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?
- A. Isograft
- B. Autograft (Correct Answer)
- C. Xenograft
- D. Allograft
Explanation: ***Autograft*** - An **autograft** is a type of graft where tissue is transplanted from one site to another on the **same individual**, which matches the clinical scenario described. - This is the most common type of skin graft because there is no risk of an **immunological rejection** by the recipient's body, as the tissue is genetically identical. *Xenograft* - A **xenograft** (or heterograft) involves the transplantation of tissue between individuals of **different species**, such as using pig skin for a temporary burn dressing on a human. - This is incorrect as the graft was taken from the patient themselves, not from an animal source. *Allograft* - An **allograft** (or homograft) is a graft of tissue between two genetically **non-identical individuals** of the **same species**, such as a cadaveric skin graft. - This is not the correct answer because the donor and recipient are the same person, not two different people. *Isograft* - An **isograft** (or syngeneic graft) is a tissue transplant between two genetically **identical individuals**, specifically **identical twins**. - While isografts also avoid immune rejection, this is incorrect because the graft was from the patient's own body, not from their identical twin.
Question 14: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?
- A. Urgent surgery
- B. Blood transfusion
- C. Wait and watch
- D. Esmolol and urgent surgery (Correct Answer)
Explanation: ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.
Question 15: A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?
- A. Steroidal injection
- B. Sclerotherapy
- C. Avoid smoking; wait and watch
- D. Local excision and biopsy (Correct Answer)
Explanation: ***Local excision and biopsy*** - The clinical presentation of a persistent white patch in a chronic tobacco user is highly suspicious for **oral leukoplakia**, which is a **premalignant** condition. A **biopsy** is mandatory to establish a definitive histological diagnosis and rule out dysplasia or **squamous cell carcinoma**. - An **excisional biopsy** for a localized lesion is both diagnostic and therapeutic, as it removes the potentially malignant tissue and allows for microscopic examination. *Avoid smoking; wait and watch* - While smoking cessation is a critical part of management, a "wait and watch" approach is inappropriate for a lesion that has persisted for 7 months due to the significant risk of underlying malignancy. - Delaying a definitive diagnosis could allow a potential early-stage cancer to progress, leading to a worse prognosis. *Steroidal injection* - Steroids are used to treat **inflammatory** or **autoimmune** oral lesions like oral lichen planus or pemphigus vulgaris, not potentially neoplastic conditions like leukoplakia. - Using steroids could mask the progression of the lesion and delay the diagnosis of a malignancy. *Sclerotherapy* - Sclerotherapy is a treatment used for **vascular lesions**, such as **hemangiomas** or venous malformations, where a sclerosing agent is injected to cause thrombosis and fibrosis. - This modality is completely inappropriate for an **epithelial** lesion like leukoplakia.
Question 16: A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?
- A. Rebound tenderness
- B. Hypotension
- C. Copious sero-sanguinous discharge (Correct Answer)
- D. Hemorrhage
Explanation: ***Copious sero-sanguinous discharge*** - An abrupt increase in **sero-sanguinous fluid** (often described as salmon-colored or pink-brown) soaking the dressing is the **surest clinical sign** of underlying fascial dehiscence. - This discharge represents peritoneal fluid leaking through the broken-down **fascial closure**, usually preceding full **evisceration**. - Typically occurs 5-10 days post-operatively and is the most specific early warning sign. *Rebound tenderness* - **Rebound tenderness** is a sign of **peritonitis** or intra-abdominal inflammation, which is related to the primary pathology (perforation) but not a direct sign of **fascial integrity loss**. - If present post-operatively, it usually indicates persistent or recurrent **intra-abdominal sepsis**, abscess, or ongoing peritonitis. *Hemorrhage* - **Hemorrhage** (frank bleeding) indicates vascular injury or a defect in **hemostasis**, not mechanical failure of the fascial layer itself. - Significant wound bleeding is common in the immediate post-operative period but is not the specific pathognomonic finding for **wound dehiscence**. *Hypotension* - **Hypotension** is a non-specific sign of severe systemic compromise, such as **sepsis**, **hypovolemic shock**, or ongoing internal bleeding. - Although a major dehiscence could lead to sepsis and subsequent hypotension, it is not the initial or most **specific indicator** of the structural breakdown of the wound.
Question 17: Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?
- A. Gaze palsy is - Midbrain lesion (Correct Answer)
- B. b.Penetrating injury to eustachian tube- CSF otorrhea
- C. c.Penetrating injury to eye- Battle sign
- D. a.Extradural hemorrhage (EDH)- Pin point pupil
Explanation: ***Gaze palseis-Mid brain lesion***- **Vertical gaze palsies** are commonly associated with lesions affecting the **midbrain**, particularly the **pretectal area** and the rostral interstitial nucleus of the **medial longitudinal fasciculus (riMLF)**.- Trauma or increased intracranial pressure leading to compression in this region, such as in **Parinaud syndrome**, can result in impaired upward or downward gaze.*Extradural hemorrhage (EDH)- Pin point pupil*- An **EDH** typically causes rapid mass effect and subsequent **uncal herniation**, leading to compression of the **oculomotor nerve (CN III)** and resulting in a fixed, **dilated pupil** (mydriasis) ipsilateral to the lesion.- **Pinpoint pupils** are classically associated with damage to the descending sympathetic pathways in the **pons** (pontine hemorrhage) or opioid overdose.*Penetrating injury to eustachian tube- CSF otorrhea*- **CSF otorrhea** (leakage of CSF from the ear) occurs due to a tear in the dura mater and the **temporal bone**, specifically involving the **petrous segment** and tympanic membrane rupture.- Injury to the **Eustachian tube** primarily connects the middle ear to the nasopharynx; damage here would typically cause air leak or middle ear bleeding, not primary CSF leakage through the external auditory canal.*Penetrating injury to eye- Battle sign*- **Battle sign** is ecchymosis (bruising) over the **mastoid process** and is a hallmark clinical indicator of a **basilar skull fracture**, usually involving the middle cranial fossa (temporal bone).- Penetrating injuries to the eye are associated with localized ocular trauma (e.g., globe rupture, hyphema) but are not typically linked to this specific sign of underlying skull base injury.
Question 18: A homosexual man complains of painful defecation and mass protruding from the anal canal. Biopsy reveals squamous cell carcinoma of anus. Correct management for this patient is
- A. Wide local excision
- B. Combined chemoradiation (Correct Answer)
- C. Chemotherapy
- D. Abdominoperineal repair
Explanation: ***Combined chemoradiation***- **Combined chemoradiation (Nigro protocol)** is the standard of care and preferred, organ-preserving primary treatment for most stages of squamous cell carcinoma of the anus.- This curative regimen typically involves sequential or concurrent use of **5-Fluorouracil**, **Mitomycin C** (or Cisplatin), and focused external beam radiation therapy, resulting in high rates of complete remission.*Chemotherapy*- Chemotherapy alone is insufficient as a curative primary modality for localized anal carcinoma and is inferior to combined treatment.- Systemic chemotherapy is primarily reserved for the management of **metastatic** disease or palliation in advanced, unresectable cases.*Abdominoperineal repair*- **Abdominoperineal resection (APR)**, which creates a permanent colostomy, is primarily reserved as a highly morbid **salvage operation** for locoregional failure following initial chemoradiation.- Primary APR is rarely performed because combined chemoradiation offers similar long-term survival rates with sphincter preservation.*Wide local excision*- **Wide local excision (WLE)** is only appropriate for very small (T1, <2cm), well-differentiated tumors located at the anal margin (perianal skin), which are much less common.- A bulky, protruding mass usually indicates a deeper primary tumor or involvement of the anal canal, requiring definitive **chemoradiation** rather than surgery.
Question 19: A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?
- A. a.Herniotomy
- B. b.Hernioplasty (Correct Answer)
- C. c.Wait and watch
- D. d.Emergency laparotomy
Explanation: ***Hernioplasty***- **Hernioplasty**, which utilizes a prosthetic mesh (e.g., **Lichtenstein technique**), is the universally accepted standard for repairing adult inguinal hernias to achieve a tension-free repair.- This method provides a **tension-free repair** of the posterior inguinal wall, leading to significantly lower recurrence rates compared to traditional suture repairs.*Herniotomy*- **Herniotomy** involves only the excision of the hernia sac and is typically reserved for **indirect inguinal hernias in children**, where the muscle wall is robust.- In an adult, failing to repair the inherent weakness of the **inguinal canal floor** after sac removal results in an unacceptably high risk of hernia recurrence.*Wait and watch*- This approach is mainly reserved for **elderly or comorbid patients** with minimally symptomatic or asymptomatic reducible hernias who are considered high risk for surgery.- For a fit 25-year-old, surgery is recommended to prevent future potentially life-threatening complications like **strangulation** or chronic pain.*Emergency laparotomy*- A full **laparotomy** is an extensive abdominal incision utilized for exploring the acute abdomen or managing complicated intra-abdominal sepsis.- This procedure is unnecessary as the hernia is described as **reducible** and **painless**, indicating an elective repair is warranted, not an emergency exploration.
Question 20: A patient presents with urinary symptoms due to benign prostatic hyperplasia. Which of the following is used to manage the urinary symptoms in the initial stage of this condition?
- A. Tamsulosin (Correct Answer)
- B. Finasteride
- C. Observation
- D. TURP-Transurethral resection of prostate
Explanation: ***Tamsulosin*** - **Alpha-1 adrenergic blocker** that relaxes smooth muscle in the prostate and bladder neck - Provides **rapid symptom relief** within days to weeks for moderate-to-severe LUTS (Lower Urinary Tract Symptoms) - **First-line medical therapy** for symptomatic BPH requiring treatment - Improves urinary flow rate and reduces obstructive symptoms (hesitancy, weak stream, incomplete emptying) *Finasteride* - 5-alpha reductase inhibitor that shrinks prostate size over time - Takes **6+ months** to show clinical benefit, not ideal for initial symptom relief - More appropriate for patients with large prostates (>40g) or as combination therapy *TURP (Transurethral Resection of Prostate)* - **Surgical intervention** reserved for refractory cases, complications, or failure of medical management - Not appropriate as initial management - Indications: recurrent retention, refractory hematuria, bladder stones, renal insufficiency due to BPH *Observation* - Appropriate for **asymptomatic or mildly symptomatic** patients (watchful waiting) - This patient presents with urinary symptoms requiring active management - Not suitable when symptoms are bothersome enough to prompt medical consultation